Healthcare Provider Details

I. General information

NPI: 1124743125
Provider Name (Legal Business Name): COURTNEY JENEL OLOUGHLIN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: COURTNEY JENEL SELDERS PA-C

II. Dates (important events)

Enumeration Date: 10/11/2022
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1507 PARK CENTER DR UNIT 1D1E
ORLANDO FL
32835-5795
US

IV. Provider business mailing address

151 SOUTHHALL LN STE 300
MAITLAND FL
32751-7172
US

V. Phone/Fax

Practice location:
  • Phone: 866-400-3376
  • Fax: 407-293-3908
Mailing address:
  • Phone: 866-400-3376
  • Fax: 407-650-3455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9116521
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: